History of Endodontics aae/abe

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How long does apexification take?

Cvek – 18.2 months; Yates – 9 months; Kleirer – 12 months

Considerations for Immature teeth to prevent fractures during apexification
Trope – strengthen cervical portion of immature teeth with composite during apexification to prevent fractures.
Goldberg – use resin modified glass ionomer after apexification to increase resistance to fracture in immature teeth with total crown loss.

Kerekes – 30% Fractures after long term CaOH2

Materials used to form apical barrier in cases with an open apex

Dentin Chips

  1. Brady – apical dentin plug promotes a severe periapical response and inhibits cementum/bone formation


  1. Torabinejad – CaOH2 induction of root end closure (apexification)

  2. El-Meligy – CaOH2 = MTA for Apexification success


  1. Andreasen – in a guide for traumatic injuries, he recommends:

    1. MTA apexification after 2-4 wks of CaOH2, MTA thickness should be 4 mm (Lawley;Al-Kahtani 4 mm >2 mm-leakage)

  2. Torabinejad – Apexification w/MTA, place CaOH2 for 1 wk in infected cases, place MTA, close w/wet cotton/cavit, obturate 4 hours. Induces formation of cementum.

  3. Holland;Baek – MTA permits cementum attachment/growth over surface and reattachment of PDL (extrusion of MTA not an issue)

  4. Andreasen – Long term MTA does NOT  dentin fracture strength

MTA Artificial Barrier Technique (Open Apex)

4 mm apical plug MTA (Lawley; Al-Kahtani), GP or composite coronally

  1. Mente 2013 – Cohort study- 252 open apex teeth treated with MTA apical plugs, Min follow up 12 months (avg 21 months), Findings: 90% Healed (85% w/AP, 96% w/o AP), Presence of AP significantly  Prognosis. (Healed = PAI 2, No clinical signs/symptoms)

  1. Jeeruphan/Hargreaves 2012 – Pulpal regeneration vs. MTA apexification vs. CaOH2 apexification, Immature necrotic teeth. Minimum 6 month Recall. Findings Root length: Revasc>MTA>CaOH2; Root width: Revasc>CaOH2>MTA; Survival (Healed + Healing): Revasc (100%) >MTA Apex. (95%)>CaOH2 Apex. (77%)

  1. Witherspoon JOE 2008 – Retrospective study, 144 open apex teeth treated with MTA apexification in 1 visit or 2 visit (w/CaOH2). Recall 1 year. Success (Healed + Healing): 1 visit = 93.5%, 2 visit = 90.5% NSD

See also Holden/Schwartz: 85% Healed at 12 months

What is the prognosis for formocresol pulpotomy in Primary teeth? (Formocresol = Buckley)

  1. Shelton 2000 Ped Dent. – Success rates are: 93% for indirect pulp cap, 74% for formocresol pulpotomy

  1. Fuks 1997 Ped Dent. – This study compared the use of ferric sulfate with formocresol for use in pulpotomy in primary teeth. NSD was found in the success rates between the two materials. 92% ferric sulfate vs 84% formocresol. Diluted Formocresol as Successful as Full Strength!

  1. Waterhouse 1995 EDT – This study reviewed the success rates for pulpotomies in primary teeth with various medicaments.

    1. Formocresol 55-98% - cytotoxic, mustgenic, carcinogenic

    2. CaOH2 31-100%

    3. Glutaraldehye 82-98%

  1. Holan/Fuks 2005 – Pulpotomy Success (16 mos): MTA: 97%, Formo: 83%

Discuss the prognosis of direct pulp cap tx for carious exposures

  1. Barthel 2000 JOE – Retrospective study after 5 & 10 years of pulp cap success (CaOH2): Time dependent failure of CaOH2 (see Mente)

    1. 44.5% failures, 5 yrs // 79.7% failures, 10 yrs

    2. 18.5% questionable, 5 yrs // 7.3% questionable, 10 yrs

    3. 37% successful, 5 yrs // 13% successful, 10 yrs

  1. Lovschall 2002 Endo Topics – Vital pulp therapy highly successful with careful case selection and observation of intricacies of technique. (97% at 1 yr, 82% at 5 yr)

    1. Case selection – no clinical or radiographic signs of pulpitis

    2. Technique –

      1. Gentile

      2. No interference of blood clot between pulp and material

      3. Do not introduce infected dentin chips or material into pulp

Discuss the prognosis of direct pulp cap tx for carious exposures

  1. Langeland 1971 OOO – Best tx for carious pulp exposure is teeth with complete roots is RCT, since enough toxic products remain in pulp to maintain inflammation.

  1. Tronstad 1972 OOO – Direct pulp capping of carious pulps had less than a 50% chance of success. It should be considered IP and RCT provided.

  1. Mente – Direct pulp capping with MTA vs. CaOH2, 1+ yr recall, Caries or Mechanical, Immature/Mature. MTA: 78%, CaOH2: 60%. Teeth restored  2 days after pulp cap had significant prognosis. MTA better for direct pulp cap.

  1. BogenYoung teeth (OPEN apices), 1-9 year recall, Reversible Pulpitis and Carious pulpal exposures, Success: 98%

What are the properties of the dentin bridge formed?

  1. Pisanti 1964 Jdent Res. – Calcium in the newly formed tertiary dentin comes from the pulp and not from the CaOH2 base.

  1. Nair 2008: MTA: @ 1 week – no inflammation, @ 3 months – compact barrier formation. Dycal: @ 3 months – presence of persistent inflammation and hard tissue barrier with tunnel defects. MTA > CaOH2 for inflammation and dentinal bridge formation

  1. Goldberg 1984 JOE – Dentinal bridge formed with CaOH2 is porous and permeable.

  1. Holland/deSouza 1999 – MTA reacts with tissue fluid to form CaOH2 resulting in hard tissue formation in similar manner as CaOH2. MTA also releases soluble growth factors to stimulate hard tissue (reparative dentin) formation (Smith). Source of Ca+2 is pulp.

Discuss Indirect pulp capping pros and cons ?

  1. Massler 1977 OOO – Pain is the most important diagnostic tool in deciding vital pulp therapy. Deep carious lesions w/o exposure are AFFECTED and will repair themselves. Exposed lesions are INFECTED w/ bacteria.

  1. Stanley 1966 OOO – Following operative procedures, the formation of tertiary dentin began at 19 days and the average formation rate was 1.49 micrometers/day.

  1. Reeves/Stanley 1966 OOO – If bacteria were 1.1 to 2.4 mm from the pulp, little pulpal pathology was observed. If bacteria were within 0.5mm or invaded reparative dentin, irreversible pulpal damage was observed.

  1. Langeland 1987 EDT – “Affected” hard dentin of cavity floor contains bacteria, therefore indirect pulp capping is not a good idea.

  1. Murray/Smith – RDT <0.5 mm = injury to odontoblasts, microbial leakage into pulp

Histology: MTA vs. CaOH2 for Direct Pulp Capping?

  1. Holland 2001 Dent Trauma – Comparison of CaOH2 vs. MTA for pulp capping in dogs. Healing w/MTA showed complete tubular dentin bridge formation and no inflammation. Mechanism of action believed to be similar to CaOH2. MTA provided a superior bacteria-tight seal.

  1. Nair 2008 – Human RCT, Compared MTA vs Dycal for iatrogenic pulp capping (healthy 3rd molars). MTA: @ 1 week – no inflammation, @ 3 months – compact barrier formation. Dycal: @ 3 months – presence of persistent inflammation and hard tissue barrier with tunnel defects. MTA > CaOH2 for inflammation and dentinal bridge formation

  1. Smith - MTA stimulates the release of soluble growth factors (i.e.: DSPP, BMP, TGF) from dentin, promoting reparative dentin formation. Avoid RMGIs (i.e.: vitrebond), composite resins – intense inflammatory response, greater bacterial peneration and cytotoxic effects

MTA vs. CaOH2 Pulp Capping

  1. Pitt Ford/Torabinejad 1996 – Introduced MTA as pulp capping material

  1. Farsi 2006 - 30 Young Permanent Molars (73% open apices) Asymptomatic and Carious pulpal exposures, MTA Pulp cap, 12-24 month Recall, Success (Clinical/Radiographic/Cold Testing): 93% @ 24 months

  1. Bogen 2008 – 53 teeth (15 open apices, ages 7-45) w/ Reversible Pulpitis and Carious pulpal exposures, 10 min NaOCl/cotton pellet hemostasis, MTA Pulp cap (2 visits), 1-9 year Recall, Success (Clinical/Radiographic/Cold Testing): 98%

  1. Mente 2010 – 108 teeth (C.C.), Direct pulp cap with MTA vs. CaOH2, 1+ yr recall, Caries or Mechanical, Immature/Mature. MTA: 78%, CaOH2: 60%. Teeth restored  2 days after pulp cap had significant prognosis. No time dependent  in success of MTA pulp cap (CaOH2 did ). MTA appears to be superior to CaOH2 for pulp capping (Not statistically signficant)

MTA vs. CaOH2 Pulpotomy

  1. Barrieshi-Nusair 2006 – Evaluated MTA for Partial Pulpotomy in young permanent molars with carious exposures and Reversible Pulpitis/Normal periradicular tissues. 24 month Recall. Success: 28/28 (100%) (Clinical/Radiographic). 78% responded to sensibility testing at recall.

  1. El-Meligy 2006 – Evaluated MTA as Pulpotomy agent in young permanent teeth, 1 year Recall, Success (Clinical/Radiographic): CaOH2 13/15, MTA 15/15. MTA is suitable for pulpotomy. Better dentinal bridge with MTA (See Holland; Torabinejad; Nair)

  1. Witherspoon 2008 – 19 immature vital teeth (ages 7-15) with carious or traumatically exposed pulps diagnosed with Symptomatic Irreversible Pulpitis were treated with MTA Pulpotomies (vital pulp therapy). 21 month Recall. 18/19 (95%) were classified as healed or healing (cont. root growth, asymptomatic). 75% responded to sensibility testing at recall.

Vital Pulp Therapy Review – Witherspoon JOE 2008

  1. Goals: Eliminate bacterial infection, Treat uninflammed pulp, Create bacterial tight seal, Allow continued root development and pulp vitality for function

  2. Properties of Material: Antibacterial, Bacterial tight seal, Induce hard tissue formation, Non-cytotoxic to tissues

  3. MTA:

    1. Antibacterial (facultative only - Lovato/Sedgley)

    2. Resists bacterial leakage (Torabinejad; Fischer)

    3. Induces hard tissue formation with more complete barrier formation/less inflammation of pulpal tissues (Holland; Nair)

  4. Direct Pulp Capping: Farsi (93%), Bogen (98%), Mente (78%)

  5. Pulpotomy: Barrieshi-Nusair (100%)-PP, Witherspoon (95%)-FP

  6. Technique: Affected pulpal tissue removed w/highspeed diamond bur, Flush with 6% NaOCl for up to 10 mins (Cox). Note: Avoid direct cotton pressure to pulp – traumatizes tissues, leaves fiber remnants. 2 mm MTA layer over tissue. Flowable compomer/G.I./RMGI placed followed by bonded c.r.

  7. Assessing health of pulp tissue: Ability to gain hemostasis with 6% NaOCl!!

What is the effect of pulp disease/trauma in primary teeth? Does it affect the permanent tooth? Does Tx?

  1. Andreasen 1978 Int J Oral Surg – NO effect on odontogenesis of permanent teeth in monkeys after induced pulpal and periradicular inflammation

  2. Holan 1992 EDT – Trauma of primary dentition treated with RCT induced enamel defects in permanent teeth as compared to extraction or no treatment. Despite findings RCT is still recommended as opposed to extraction to prevent speech problems, premature eruption and / or malalignment problems or affect the child’s self image.

  3. Sonis 1987 J Pedo – Traumatized ant tooth which becomes necrotic w/out radiolucency or clinical pathosis will not effect developing succedaneous tooth. If pathology develops, ext will minimize potential effect to permanent tooth.

  4. Torneck 1982 DCNA – Trauma to primary tooth may alter development of the permanent success

Is Formocresol Safe?

Formocresol is Buckley’s Formula 1:5 dilution

  1. Pashley 1980 – Dog study – formocresol was detected throughout the body (spleen, liver and kidney). Systemic spread is possible.

  1. Sipes 1986 – States that use is questionable due to potential mutagenicity, carcinogenicities and humoral immune response. Formo will cause tissue damage when not used carefully.

  1. Ribeiro 2004 JOE – Formocresol, paramonochlorophenol and calcium hydroxide do not promote DNA damage in mammalian cells.

Regenerative Endodontics

Regeneration vs. Revascularization


Definition - Biologically based procedures designed to replace damaged structures, including dentin and root structures, as well pulp-dentin complex cells


  1. Tissue engineering – Placement of Stem cells, Scaffolds, and Growth factors into pulp space to form new pulp-dentin complex

  2. Replication of embryonic tooth formation/artificial tooth germs


Definition – Restoration of the vascular supply to the pulp-dentin complex


  1. Triggering bleeding into an empty root canal space similar to blood clot in surgical wound healing (no use of stem cells or growth factors)

Goal of Regenerative Endodontic Procedures: Regeneration of the entire pulp-dentin complex (cellularity, vascularity, dentin/pulpal tissues) w/in exisitng tooth utilizing bioengineering principles of stem cells, scaffolds, and growth factors

Tissue Engineering (Triad) – SSGs – Stem cells, Scaffolds, GFs
Postnatal Mesynchymal Stem Cells (5 types):

  1. SCAP – Stem Cells of Apical Papilla

    1. Nakashima – periapical tissues contain an enriched population of mesychymal stem cells; Triad of stem cells, scaffolds, growth factors

    2. Lovelace/Hargreaves – Evoked bleeding in canal released 600 fold increase of mesynchymal stem cell markers into the canal system of immature teeth, possibly SCAP cells

  2. SHED – Stem cells of Human Exfoliated Deciduous teeth (primary teeth)

  3. DPSC – Dental Pulp Stem Cells

    1. Gronthos 2000 – isolated DPSCs, implanted in mice, dentin-like, pulp-like, and odontoblast-like cells formed

  4. DFPC – Dental Folicle Progenitor stem Cells

  5. PDLSCs – Periodontal Ligament Stem Cells

Postnatal stem cells are multipotent

Embryonic stem cells are omnipotent/totipotent or pluripotent

Tissue/Bio-Engineering (Triad)

  • Scaffolds3-D support for spatial positioning of stem cells/growth factors and regulation of growth/metabolism, supports proliferation/differentiation

  1. Natural

  1. PRP – Platelet Rich Plasma

  2. PRF – Platelet Rich Fibrin

  3. Collagen

  4. Blood clot (Endo Regen Procedure)

  1. Synthetic

    1. PLA (polylactic acid), PGA (polyglycolic acid), PLGA, bioceramics, hydrogels, fibrin gels

  • Growth Factors – bind to stem cells to trigger proliferation/differentiation

  1. Fibroblastic Growth Factor

  2. TGF- (Zhao)

  3. NGF

  4. BMP



Nygaard Otsby 1961

  1. 1st to evaluate regenerative endodontic procedures – described revascularization procedure of lacerating the periapical tissues to form blood clot within the canal space (Based on surgical wound healing principles)

  2. Found ingrowth of connective tissue into the canal space and cementum deposition on canal walls.

Banchs/Trope 2004 - Case report – 11 yo male/open apex/AP, #29, Revasc

(See also Iwaya 2001 - 1st case report on revascularizaton)

Is Regeneration considered Apexification or Apexogenesis?

Apexogenesis: Vital pulp therapy aimed at continued physiologic root development with No loss of vascularity (no need to revascularize the canal space)

Apexification: Inducing calcific barrier in a root with an open apex or continued root development of an incompletely formed root in teeth with Necrotic pulp

  • Regenerative Endodontics would be considered Apexification

Currently in Regenerative Endodontics

Source: AAE

Current Regenerative Endodontic Protocols rely on:

  1. Irrigants to disinfect (1.5% NaOCl, TAP) and release of growth factors found in dentin – DSPP, TGF, NGF (17% EDTA)

  2. Stimulate bleeding from the periapical tissues to promote influx of stem cells (SCAP) and growth factors

  3. Blood clot and dentinal walls provide the scaffold for generation of new tissues

Future Regenerative Endodontics:

  1. Autologous stem cells seeded on customized scaffolds and delivery of appropriate growth factors

  2. Hydrogels and autologous stem cells

Regenerative Endodonic Procedures (REPs)

Law JOE 2013 – Considerations for Regenerative Procedures

Case Selection:
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